RESEARCH IDEAS

Suggested useful research topics in neuropsychology in South Africa

With so many languages spoken in South Africa, and so many of the cognitive tests used in neuropsychological assessment coming from western, English-speaking countries, it is difficult to conduct linguistically fair neuropsychological tests in our country with non-English first language patients. Even more difficult, is the assessment of language functions. As a result, many psychologists neglect to assess language ability in which case they may miss vital information about the person’s neuropsychological functioning.

In a study by Gagiano and Southwood (2015), English and Afrikaans sentences and sequences of numbers were constructed, and five-year old children with and without language impairment were assessed, being required to repeat aloud what they heard on a recording. The study found that the repetition of sentences, in particular, distinguished the children with and without language impairment. This, and that Martinis (2010) found that sentence repetition provides information on a child’s language skills that is independent of the influence of environmental factors, is a good reason to do further research on sentence repetition in various languages.

Suggested research:

  • Following the same procedures as described in the study by Gagiano and Southwood (2015), other sentences in other languages can be constructed and they can be tested for their sensitivity to language impairment.

Variations on the theme:

  • The sentences that were found to differentiate between children with or without language impairment can be tested on normal healthy controls to get a normative data to which patients can be compared.

References:

Gagiano, S. & Southwood, F. (2015). The use of digit and sentence repetition in the identification of language impairment: The case of child speakers of Afrikaans and South African English. Stellenbosch Papers in Linguistics, 44, 37-60. https://spil.journals.ac.za/pub/article/view/187.

Marinis, T. 2010. Sentence repetition. Paper presented at the Third Meeting of COST Action
IS0804, 27-29 October, Larnaca, Cyprus.

Tests of vocabulary form an important part of many tests, particularly many IQ tests such as  the Wechsler Intelligence Scale for Chlidren – fifth edition (WISC-V), the Wecshler Adult Intelligence Scale (WAIS-IV) and the Wechsler Abbreviated Scale of Intelligence (WASI). The tests of vocabulary are correlate well with IQ and have been found to be useful in estimating pre-morbid intellectual ability (Lezak et al., 2012).

However, since these tests were developed in an English-speaking country, the vocabulary words are in English and since most people in South Africa do not have English as a first language, these tests are not good measures of vocabulary for most people in South Africa.

Suggested research:

  • To devise new tests of vocabulary in languages other than English, that correlate with valid measures of IQ.

Variation of the theme:

  • Explore the comparability of the tests of vocabulary in different languages with each other.
  • To develop lists of vocabulary that are in the same language, that can serve as alternate forms to each other.
  • To explore the effects of first language vs language of education on performance on the new vocabulary tests.
  • To explore the correlation of the new vocabulary tests with verbal and non-verbal measures of IQ,

References:

Lezak, M.D., Howieson, D.B., Bigler, E.D., & Tranel, D. (2012). “Neuropsychological Assessment”, 5th ed. Oxford University Press,

List-Learning tests such as the Rey Auditory Verbal Learning Test (RAVLT) or the List Memory of the NEPSY II test, are popular tests of verbal learning (Lezak, 2012; Strauss, et al., 2006).

The tests typically consist of a list of 15 words.  The words are read to a patient at the pace of one word per second and after the full list of words has been read to the patient, the patient is asked to recall all the words that they can. This is Trial I of the test.  After Trial I, the list of words is read to the patient again, and again the patient is asked to recall all the words he/she can, including the words recalled before.  This is Trial II of the test.  This same process is repeated for Trials III, IV and V.

After Trial V, a second list of words is read to the patient and the patient is required to recall the words from that list (List B).  The person is then asked to recall all the words from the first list (Trial VI).

After a half-hour delay, the person is again asked to recall all the words that from the first list.  Once the person can no longer recall any words, the person is given a recognition form with the 15 words from the first list, mixed with words from the second list and 30 foils with similar semantic and phonemic qualities.  The patient is instructed to indicate which words were on the first list.

There are certain patterns of learning that is expected with a normal, healthy individual.  For example, with such a list-learning test, it is expected that the person’s recall of the first list increases with each of the Trials I-V.  It is also expected that the person’s recall of the first list in Trial I will be similar to the recall of the second list when that one has been read to them, as both measure immediate memory.  It is also expected that the recall of the first list on Trial V will be similar to the recall of that list on Trial VI and again with the delayed recall trial.

The RAVLT has been translated into Afrikaans, Sepedi, Sesotho, Tswana, Venda, Xhosa and Zulu in South Africa.  The List Memory subtest of the NEPSY II has been translated into Xhosa, Zulu, Afrikaans, Sepedi, Setswana and Sesotho.  A South African List Learning Test (Blumenau, 2011), where English words that are more familiar to the South African public was used, has also been devised.

Suggested research:

  • To compare the patterns of learning on list-learning tests translated into different languages.

Variation of the theme:

  • Different ages of children can be tested to try to establish a pattern of learning as memory and executive functions mature.

Please leave a reply/comment below, especially if you are thinking of doing this research.

References:

Blumenau, J. & Broom, Y.  (2011) “Performance of South African adolescents on two versions of the Rey Auditory Verbal Learning Test”, South African Journal of PsychologyVolume 41 (2)

Lezak, M.D., Howieson, D.B., Bigler, E.D., & Tranel, D. (2012). “Neuropsychological Assessment”, 5th ed. Oxford University Press, Oxford.

Strauss, E., Sherman, E.M.S, & Spreen, O. (2006). “A Compendium of Neuropsychological Tests: Administration, Norms and Commentary”, 3rd Ed. Oxford University Press, Oxford.

Neuropsychological assessments are often done to determine if there has been a deterioration in a patient’s functioning due to, for example, dementia or a traumatic brain injury.  The test scores are mostly meaningless, though, if the examiner does not have some indication or an estimate of how the person performed pre-morbidly.  To illustrate, if a patient scores in the average range for most cognitive tests but used to function at a significantly higher level, then the average scores are significantly low.  If you did not know that the patient had such high functioning pre-morbidly, then you might come to the wrong conclusion that his functioning has not deteriorated.

There are several ways to estimate pre-morbid functioning, and research has shown that certain tests are fairly resilient to brain insult (Lezak, 2012).  There does not seem to be any research, though, into the validity of those tests in the South African population.

One of the methods of estimating pre-morbid functioning, is to test a patient’s vocabulary (Lezak, 2012).  Since most of these tests (such as those found in the Wechsler IQ tests) are in English, this approach cannot be used with any confidence with the majority of South Africans whose first language is not English.  Even with English first language speakers, level and quality of education is likely to interfere with the validity of such a method.

Research is needed into suitable measures of pre-morbid functioning for South Africans.

Specific suggestions:

  • Vocabulary tests can be devised for different South African languages and different cultural groups and compared with measures of IQ to determine compatibility.
  • The non-verbal tests that have been found to be resilient to brain injury in westernised groups can be evaluated on South African groups.  Non-verbal tests found to provide good pre-morbid estimations in westernised persons are the Picture Completion (Krull, et al., 1995), Block Design and Object Assembly (Vanderploeg & Schinka, 1995) of the Wechsler tests .  (This research was done using the old WAIS-R and would need to be evaluated using the newest version of the WAIS.).
  • Word-reading tests have been found to be good estimators of pre-morbid ability because they tap into a person’s knowledge of how to pronounce words when they are read.  Examples of these tests are the National Adult Reading Test (NART) and the Wechsler Test of Adult Reading (WTAR).  Research can be done into devising suitable alternatives to these tests in the major South African languages, taking level and quality of education into account.
  • Demographic variables are sometimes used to estimate pre-morbid functioning.  A study can be done on the efficacy of this method in our diverse cultures.
  • Number of years of schooling and quality of schooling (e.g. township schooling vs. private schooling) can be evaluated as a pre-morbid indicator by comparing results of IQ tests done on persons with the different levels and quality of schooling.
  • Occupational history of family members are also often used to help with pre-morbid estimation of patients. The validity of this method can be explored.
  • The Spot the Word test (now in its second edition, Baddeley & Crawford, 2012) is a test to measure pre-morbid functioning and can be used with people who have difficulty with speech.The examinee is required to recognise words and distinguish them from non-words. A study can be done where this test is adapted for various languages spoke in South Africa, where the validity and reliablity is explored (particularly in the light of reading levels of examinees) and normative data collected in the process. Alternately, the test can be kept in its original English form and, the correlation between the test results and English reading level can be explored.

References:

Baddeley A, Emslie H, Nimmo-Smith I. The Spot-the-Word test: a robust estimate of verbal intelligence based on lexical decision. Br J Clin Psychol. 1993;32(1):55-65. doi:10.1111/j.2044-8260.1993.tb01027.x

Krull, K.R., Scott, J.G., & Sherer, M. (1995).  Estimation of premorbid intelligence from combined performance and demographic variables.  The Clinical Neuropsychologist, 9, 83 – 88.

Lezak, M.D., Howieson, D.B., Bigler, E.D., & Tranel, D. (2012).  Neuropsychological Assessment.  Oxford University Press: Oxford.

Vanderploeg, R.D. & Schinka, J.A. (1995).  Predicting WAIS-R IQ premorbid ability: Combining subtest performance and demographic variable predictors.  Archives of Clinical Neuropsychology, 10, 225 – 239.

Our bodies are usually paralysed during REM sleep.  This is probably necessary so that one does not respond physically to what one is dreaming about in that time. This paralysis is supposed to end once a person awakes, but this is not always the case and occasionally a person becomes fully awake, but is left with the paralysis of the head, limbs and trunk.  Along with the paralysis, persons typically experience respiratory difficulties and anxiety.

This transient experience is fairly common and is called Sleep Paralysis.  What makes it very interesting, though, is that different cultures have been found to have different interpretations of the experience and the explanations they give typically fall in the realm of the supernatural.  People experiencing Sleep Paralysis tend to explain it as a very fearful experience in which they sense an evil presence near them and experienced pressure on the chest (as if something is sitting on their chest or trying to suffocate them).

Research has shown that the supernatural explanations of the experience of Sleep Paralysis tend to be grouped culturally.  In other words, persons within certain cultural groups tend to have similar beliefs regarding the cause of Sleep Paralysis.  For example, persons from Newfoundland in Canada are likely to blame the “Old Hag”, persons in Thailand will blame the “phi am” (a certain ghost)(Cassaniti, 2011), and those in Egypt will blame if on the Jinn (malevolent spirit-like creatures) (Jalal, 2013).  Similar cultural groupings of explanations have been found in Mexico (Sharpless & Doghramji, 2015), Japan (Kukuda, et al., 1987), Ethiopia (Sharpless & Doghramji, 2015), Brazil (Adler, 2011), China (Yeung, et al., 2005), Nigeria (Aina & Famuyiwa, 2007), and more.  Reports of “alien abduction” have also been attributed to the cultural interpretation of Sleep Paralysis (Shermer, 2011).

It seems that cultural interpretations of Sleep Paralysis have not been explored in South Africa yet, though.  With such diverse cultures in South Africa, such research is likely to yield very interesting results!

Idea for research:

  • Explore the prevalence of Sleep Paralysis in different South African cultures and their cultural interpretations of such experiences.

Variation on the theme:

  • Explore the effect on experiences and levels of anxiety in sufferers of Sleep Paralysis if they are given a biological explanations of the Sleep Paralysis experience.

References:

  • Aina O. F., Famuyiwa O. O. (2007). Ogun Oru: a traditional explanation for nocturnal neuropsychiatric disturbances among the Yoruba of Southwest Nigeria. Transcult. Psychiatry 44 44–54. 10.1177/1363461507074968 [PubMed] 
  • Adler S. R. (2011). Sleep Paralysis: Night-Mares, Nocebos, and the Mind-Body Connection. New Brunswick, New Jersey, and. London: Rutgers University Press.
  • Cassaniti J., Luhrmann T. M. (2011). Encountering the supernatural – a phenomenological account of mind. Relig. Soc. 2 37–53.
  • Dahlitz, M. & Parkes, J.D. (1993). Sleep paralysis. Lancet, 341, 406–407.
  • Firestone M. (1985). The “Old Hag”: sleep paralysis in Newfoundland. J. Psychoanal. Anthropol. 847–66.
  • Fukuda K., Miyasita A., Inugami M., Ishihara K. (1987). High prevalence of isolated sleep paralysis: kanashibari phenomenon in Japan. Sleep 10 279–286. [PubMed]
  • Jalal B., Hinton D. E. (2013). Rates and characteristics of sleep paralysis in the general population of Denmark and Egypt. Cult. Med. Psychiatry 37 534–548. 10.1007/s11013-013-9327-x [PubMed]
  • Shermer M. (2011). Por Que as Pessoas Acreditam em Coisas Estranhas: Pseudociência, Superstição e Outras Confusões dos Nossos Tempos. São Paulo: JSN Editora.
  • Sharpless B. A., Doghramji K. (2015). Sleep Paralysis – Historical, Psychological and Medical Perspectives. Oxford: Oxford University Press.
  • Yeung A., Xu Y., Chang D. F. (2005). Prevalence and illness beliefs of sleep paralysis among chinese psychiatric patients in China and the United States. Transcult. Psychiatry 42 135–145. 10.1177/1363461505050725 [PubMed]

There seems to be an increasing number of children in South Africa diagnosed with ADHD, with increasing use of methylphenidate (e.g. Ritalin and Concerta) for treatment purposes.  While many psychologists express discomfort with what some believe to be an over-use of methylphenidate for treatment purposes, there seems to be little research in South Africa into alternatives to pharmacological treatment.

Since ADHD can be considered a neuro-behavioural/psycho-behavioural problem, it seems fitting that psychologists take the lead in exploring alternative treatments such as cognitive-behavioural interventions, behavioural modifications and/or lifestyle changes.

Examples of research that can be undertaken:

  • Efficacy of certain lifestyle changes in improving ADHD symptoms can be compared e.g. regular physical exercise compared to behavioural modification programmes.
  • Changes in sleep habits can be explored in an attempt to reduce ADHD symptoms.
  • Parenting styles and/or attitudes and their possible relationship to ADHD symptoms can be compared.
  • Age of exposure and amount of exposure to “screen time” e.g television, tablets and mobile phones and its relationship to ADHD symptoms can be explored.

The NEPSY II test for children aged 3 – 16 years, has been translated into Afrikaans, isiXhosa, isiZulu, Setswana, Sepedi and Sesotho.  The List Memory subtest of the NEPSY II is very similar to the Rey Auditory Verbal Learning Test (RAVLT) and is a good test of immediate memory, verbal learning and delayed verbal memory.  Having the test in the different languages makes it potentially very useful in the assessment of many South Africans.

The NEPSY II List Memory subtest has one draw-back, though: it does not have a recognition format as the RAVLT does.  A recognition format is where the words from the list that is learned in the test, are presented with other words, and the patient is asked to identify only the words that were on the list.  The benefit of this additional task is that it reveals whether verbal delayed recall problems are due to storage difficulties or retrieval difficulties.

Researchers wanting to investigate this, will need to design a recognition format.  It is recommended that they do so based on the principles of the RAVLT Recognition Format (as explained in Lezak’s “Neuropsychological Assessment“).  Once the recognition format has been designed, several healthy children would need to be tested in the List Memory subtest along with the new recognition format, to collect norms/to see how “normal” children fare on this test.

Variations on the theme:

  • Children from different age groups can be compared.
  • Children with high and low SES can be compared.
  • Recognition formats can be designed for each of the six South African languages into which the NEPSY II has been translated and the performance on the different list learning tests and recognition formats compared.

HIV +ve mothers are often given antiretroviral medication to prevent their babies from being born HIV +ve.  However, an observation was made by one of the psychologists in our country that these babies seem to have cognitive deficits despite being born HIV-ve.  Could it be that the antiretroviral medication is negatively affecting the brain development of these children in utero?

As a preliminary study into this this, a researcher can test young children from similar social circumstances, but some from mothers who are HIV -ve, some from mothers who are HIV +ve who are not on ARV’s and some from mother who are HIV+ve but have been on ARV’s during their pregnancy.  Factors such as educational achievement of the parents and/or the parents’ cognitive functioning and the mother’s substance use habits during pregnancy, would need to be controlled for.

Variations on the theme:

  • Babies can be tested using the Griffiths Baby Scales or other tests of cognitive functioning of babies.
  • Older children can be tested, but then additional variables might need to be controlled for.
  • A longitudinal study can be done where the groups of children are followed and their cognitive functioning tested over several years.  (This is perhaps a study that can be done with several years’ classes of Honours and/or Master’s students; each year’s class assessing the children in the year that they do their studies.)

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